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Advocacy as a bellwether

28th October 2019

Why doesn’t advocacy lead to transformational systemic change as often as it should?

Advocacy is a bellwether that shows what’s working and what’s not in local health and social care services. It’s an early warning system. Advocacy, whether statutory under the Care Act, Mental Health Act and Mental Capacity Act or non-statutory, can pinpoint emerging trends, gaps in service, and issues. It highlights local and systemic issues.

Local authority scrutiny committees already consider complaints data, and the trends and issues this highlights, as a way to improve services. But what about advocacy data? It’s rare that advocacy data is used in scrutiny processes or to inform transformation programmes. A real missed opportunity.

Do we have culturally appropriate and effective mechanisms for people speaking truth to power? Often not. Do scrutiny committees and NHS trust governors listen to people’s voices? Do they challenge officers on how service user input was gathered and analysed? What steps were taken to make sure all voices were heard in a meaningful way? Clearly intentions are good. But our experience, working as an independent presence within the health and social care system, is that this could be so much better. And this would lead to better outcomes and more effective use of resources all round.

Current governance structures overseeing service design, delivery and transformation don’t cut the mustard in providing culturally appropriate and effective mechanisms for people speaking truth to power. The consequence of this is that we can’t guard effectively against testimonial injustice.

What is testimonial injustice? It is a well researched concept, but is rarely considered in user involvement or scrutiny. It occurs when “prejudice causes a hearer to give a deflated level of credibility to the speakers’ word … a negative stereotype introduces prejudices that cause a credibility deficit with the consequence that a person’s capacity to act as a testifier – a reliable giver of information – is impaired, or in severe cases completely destroyed”.

Often it’s associated with people with mental illness, the homeless or people engaging in substance misuse. We need to make sure we really listen to all voices. It’s simply the right thing to do. And consideration of these more marginalised and stigmatised groups can have a significant impact on the functioning and cost of the whole health and social care system.

I presented on this speaking at the Centre for Public Scrutiny’s recent annual conference on scrutiny of health and social care. I think the underlying issue is that governance structures overseeing service design, delivery and transformation do not always make sure user voice/patient voices are heard. Key questions are:

• Do the governance arrangements for transformation and service delivery include assurance around user voice?
• Has service user input been triangulated with other data (eg complaints and advocacy)?

Including advocacy feedback in scrutiny and service improvement initiatives is an important aspect to consider when designing or reviewing governance. Without it, the health and social care system is missing crucial information that can help to drive systemic change.

The presentation was well received, and has been picked up as a topic for further exploration. Jacqui McKinlay, CEO of the Centre for Public Scrutiny, said, “The challenge about the role of user voice in governance and the role of advocacy data in scrutiny was well made. It stimulated a great discussion and we’ll return to this topic in the near future.”

Judith Davey, Chief Executive, The Advocacy Project

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